LA COMUNIDAD DE LA “ORGA”

The key dimensions of knowledge from Aristoteles: episteme, techne and fronesis 2 3 4 is highly relevant even today when trying to understand development of professional

competence within health care. To become a professional implies to gain and in practice to apply professionally relevant knowledge and understanding, to apply skills and abilities, and to judge and approach work situations with professionalism. Workplace learning in a health care setting is a fundamental learning activity to gain this competence. Several studies show that students do appreciate to be there, to observe and to participate. We have found that students develop an expanding professional identity in an acute care ward community of practice. This in spite of that the community of practice does not always welcome students or support their learning, and that their motivation and curiosity is sometimes superseded by nervousness, insufficient supervision and exclusion from participation. According to Scanlon 79

the professional identity is multidimensional and it includes both individual and collective identities situated in professional practice. In study I we found that medical and nurse students experienced that workplace learning in a healthcare environment was an important part of their advancement as professionals and that they achieved more professional skills by participating in patient work. This could be linked to Foster 80 who described that becoming a professional have two main parts: gaining a degree by acquiring the necessary specialist knowledge and technical skills to perform the work as a professional; and to develop a professional identity by professional socialisation and learning how to behave as a professional.

The professional identity includes to be able to interact and collaborate interprofessionally. In study I, II and IV the interprofessional supervision was expressed as important for the

participants. In study I the opportunities to learn during interprofessional activities were appreciated. In study II the students interacted regularly with external experts for example specialised physicians, physiotherapists, occupational therapists and counsellors. In study IV the interaction with auxiliary nurses was valuable for the nurse students´ professional

development. According to Greenstock et al. 81 students’ first interaction with other health professionals often occurs during clinical placements. In study II we found that students were able to interact with a variety of staff over professional borders. We observed e.g. a

discussion between a nurse student and a senior consultant where the nurse student independently performed a medical sit-round with the senior consultant. In addition, we detected that there were several situations with unexploited opportunities for interprofessional learning, especially situations when both medical and nurse students participated. The value of such interprofessional collaboration activities as learning opportunities might have been unexplored, since the ward did not have routinely planned activities for interprofessional learning. A lot of learning over professional borders occurs in the regular health care context but these interprofessional learning activities is to our knowledge not systematically studied. However, organised interprofessional education that takes place in contexts especially designed for interprofessional learning is systematically explored. For example, Hallin & Kiessling 82 have stated that a well organised interprofessional training ward provided a supportive and permissive learning environment. Students had options to interact with one another. They perceived that they were in a safe place with space, that enabled them to move from insecurity to faith in their own capabilities. They went from chaos to clarity. We

assumed that it would be possible to achieve at least parts of such situations even in a regular health care context.

To be able to apply relevant medical knowledge, clinical skills and to make professional judgements are fundamental competences in the building of a professional identity as a physician. Questions and answers are thus a fundamental approach in medical education. The ethnographic observations showed that medical students’ interactions with staff were

characterised by such inquiries and responses. In study II & III we repeatedly saw medical students being asked medical questions that they were supposed to be able to respond to. According to Nilsson et al. 83 queries and replies was a common pedagogic strategy among senior consultants and residents when supervising. The queries varied from simple questions

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taxonomic levels from 1956 that was updated in 1994 by Anderson and published by Sosniak.84 Questions can be formulated to capture knowledge at six different levels;

Remembering - are the student able to recall or remember the information? Understanding -

are the student able to explain ideas or concepts? Applying - are the student able to use the information in a new way? Analysing – are the student able to distinguish between different parts? Evaluating – are the student able to justify a stand or a decision? Creating – are the student able to create a new product or point of view? We conclude that the queries and responses observed in study II and III was put mostly on the remembering, understanding and applying levels. We comprehended that simple questions did not seem to increase curiosity among the students. Furthermore, we concluded that most of the questions spanned medical knowledge and skills related to a diseased organ rather than to a whole human being. However, there were numerous situations with patients suffering several comorbidities, complex social situations or addiction problems that were not used as opportunities for learning. A pedagogical strategy trying to rephrase questions about observed patients to reach also the analytic, evaluating and creating levels could have a potential to substantially

increase the taxonomic learning level.

Study III showed that medical students sometimes felt and acted anxiously and in a stressed manner when they could not respond to the questions correctly, and we perceived that these situations hindered their learning process. This could be compared with Van der Zwet et al. 85 who stated that by asking students questions or by allowing students to ask questions the supervisors cared for the students. By asking questions students demonstrated their interest, initiative, motivation and enthusiasm to supervisors.

To understand the long-term outcome of graduated nurses’ undergraduate workplace learning explored in study IV, we applied Kolb’s four step cycle of experimental learning 10

: to have a concrete experience; to observe of and to reflect upon that experience; to form abstract concepts (analysis) and to generalize (conclude) based on that experience; and finally, to use the conclusions to test hypotheses in future situations, thus resulting in new experience. During the observations in study IV we did not see any signs that students were able to experience all of the four steps mentioned. We did not observe any signs of abstract conceptualisations or generalisations. However, over time, in this case two years after

graduation the participants could express a conceptualised and generalizable understanding of what they learnt during workplace learning at the observed ward. They could in retrospect describe that they appreciated the opportunity that they had to be active in stressed and shifting situations and to independently handle unfamiliar complex patient situations. These

experiences had improved their faith in their own aptitude to develop a professional identity and to be prepared to meet comparable situations as registered nurses. This could be

interpreted as that students needed to contrast their experiences from different workplaces and to wove them together to obtain a sense of the whole to use in their future profession, and that this process takes time.

Strand et al. 86 have stated that a stimulating ward in a hospital could be defined as an environment where student learning is based on partnership with supervisors, continuity and learning objectives. In study IV the interviewed nurses emphasised that it was not always clear how learning objectives related to learning activities in the workplace. Further, they underscored their relationship with patients as important and expressed that they wanted extended time for that. Supervisors could support students to spend prolonged time with patients during the placement. According to Westin et al. 87 it was during workplace learning that nurse students improved their professionalism in taking care of patients. During learning progression, students became more courageous, showed and reflected on their limitations.

In study IV we found that students participated in situations where staff had to perform medical treatments that they had not performed before. This shaped an unsecure feeling among the students. We cannot know why, but maybe it was more challenging for the supervisor to support the student when he or she did not feel confident in the situation. We found that the activities in the community of practice offered students numerous opportunities to act independently. In addition, they met patients with different diseases, which increased their knowledge and their embodied understanding. This is in line with Dall Alba & Sandberg 23

who stated that development of professional competence has two dimensions; medical expertise and embodied understanding of practice. The option to develop embodied understanding depends on the learner, his or her needs and knowledge, as well as on the arrangement of learning situations.

The students in study IV were all at the end of their educational programme and thus experienced in their student role. We argue that there is a limitation in Benners’ 21 levels of competence development; novice, advanced beginner, competent, proficient and expert. According to Benner a novice is a beginner, a newly graduated nurse, without experience of the circumstances in which he or she is expected to perform tasks. However, we found that even during undergraduate workplace learning a nurse student gains valuable knowledge and experience of the situations in which he or she is expected to perform. Therefore, nurse

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